Brief instruments for measuring nutrition literacy - the Nutrition Health Literacy Scale and the Self-Perceived Food Literacy Scale Short Form

Background A healthy diet is a critical factor in maintaining long-term health. In addition to a health-promoting food environment, the nutrition health literacy (NHL) and food literacy (FL) of the population are important in this context. This paper describes the development and validation of two short instruments to measure the nutrition literacy of the population, used in the Austrian Nutrition Literacy Survey 2021. Methods An instrument to measure NHL (Nutrition Health Literacy Scale; NHLS) has been adapted and further developed. To measure FL, the Self-perceived Food Literacy Scale by Poelman et al. has been modified and shortened (SPFL-SF). Validation of the instruments was based on data from a web survey conducted in Austria in 2021 with almost 3,000 participants aged 18 years and older. Exploratory and confirmatory factor analyses were performed to assess the factorial validity/dimensionality of the instruments. Additionally, internal consistency was assessed using Cronbach’s alpha, ordinal alpha, and McDonald’s omega. Results Both instruments demonstrate excellent data-model fit. The NHLS also shows excellent internal consistency (α = 0.91), while the SPFL-SF displays a sufficient internal consistency for all (α between 0.70 and 0.89) but one sub-dimension (resisting temptation α = 0.61). Furthermore, the distribution of the items indicates that the measures are understandable and suitable, as evidenced by the absence of missing values in the sample. In addition, the items of both instruments differ in their level of difficulty or agreement. Conclusions The NHLS and SPFL-SF are reliable and valid instruments for measuring NHL and FL in the general adult population. The brief instruments measuring the different aspects of nutrition literacy can be easily used in nutritional or evaluation studies. Further work is required to investigate other aspects of validity.


Background
The importance of nutrition for health, particularly in the prevention of obesity and non-communicable diseases, is undisputed [1].In recent years, however, the impact of nutrition behaviour and food systems on the environment and climate change has become increasingly recognized.This makes it even more important that consumers have access to a wide range of healthy and sustainable food and are motivated and able to make healthy but also informed and sustainable choices.In this context, food literacy (FL) and nutrition health literacy (NHL) are considered as crucial to maintain a healthy and sustainable diet.
This is even more important, as many countries worldwide experience a high prevalence of persons with overweight [2,3].The Austrian Nutrition Survey measured not only body weight and height, but also nutrient intake and the intake of foods from the various food groups.The survey shows that Austrians consume an unbalanced diet with too many foods of animal origin, too many foods high in sugar and not enough vegetables and fruits [4].This picture did not change much over the years [5].Major factors contributing to health promoting dietary habits are NHL and FL [6,7].
NHL is understood as a subcategory of health literacy.It refers to the extent to which individuals are able to access, understand, appraise, and apply nutrition information needed to make appropriate everyday nutrition decisions for better health and well-being [8][9][10].This understanding follows the general definition of HL as presented by the HLS-EU consortium [11].Understood as a relational concept [12], NHL does not only emerge from personal motivation and capabilities but in conjunction with the availability, accessibility, comprehensibility, quality, and user-friendliness of nutrition-related information and services.
The term FL refers to the competences and practices of healthy eating [13].Compared to NHL, FL is a broader concept, encompasses a collection of interrelated knowledge, skills, and behaviours, and extends to other determinants that may influence food decisions, such as social and cultural factors [10].In the scientific literature, the FL concept is defined more narrowly or more broadly, depending on how it is formulated [14].
During the last years, the Austrian Ministry of Health and the administration of the federal regions have developed nationwide and regional (nutrition) health promoting initiatives.To ensure the success of nutrition health promoting initiatives and to make them even more successful, initiatives should take peoples' food and nutrition competencies and motivation into account.Current measures for NHL focus primarily on a functional understanding of NHL (reading skills, comprehension of nutritional information), while those for FL are often lengthy and time-consuming [15,16].To facilitate a targeted approach, we have further developed and validated two instruments that can be used in nutrition and evaluation studies: an adapted and further developed short instrument on NHL and a modified and shortened instrument on FL [8].

Nutrition Health Literacy Scale (NHLS)
An instrument to measure NHL in adults (Nutrition Health Literacy Scale; NHLS) has been adapted and further developed.The NHLS was first developed as part of a project to measure HL in children and adolescents (NHLS-C) [17].It has been modified and extended for the use in adult populations.Based on Sørensen's concept of HL [11], the NHLS measures self-rated difficulties in accessing, understanding, appraising, and applying nutrition-related information for better health and wellbeing.The measurement of difficulty considers the relational nature of HL, as difficulties may arise from a low personal competence in processing information and/ or from a challenging information environment (e.g., in terms of availability, comprehensibility, quality, and userfriendliness, etc.).Respondents rate the difficulty of specific NHL tasks on a 5-point Likert scale (1 very difficult − 2 rather difficult − 3 neither/nor − 4 rather easy -5 very easy).A total of 16 items were used to measure NHL (4 items on accessing, 3 items on understanding, 5 items on appraising, and 4 items on applying nutrition-related information).The item set originally developed in German, was validated with nutrition experts, and shortened to 12 items, three for each process dimension, as part of the analyses.

Self-Perceived Food Literacy Scale Short Form (SPFL-SF)
The Self-Perceived Food Literacy Scale (SPFL), originally developed by a Dutch research team [18], measures individuals' self-rated competencies and practices related to healthy eating, based on 29 items covering various aspects of FL.The items are to be answered on a 5-point Likert scale (1 no, never -2 no, usually not -3 sometimes yes, sometimes no -4 yes, mostly -5 yes, always).Three items are reverse coded.The German version of the instrument was provided by the authors of a German study [19].This version was linguistically adapted to the Austrian context, modified in two places, and extended by one question.As part of the analyses, the instrument was shortened to a 20 items short form (SPFL-SF).

Data collection
The assessment of the psychometric properties of the questionnaires is based on data from the Austrian Nutrition Literacy Survey 2021 [8].Respondents were recruited from the online panel of the Austrian Gallup Institute, using a stratified random sample.In rare cases, the Austrian Gallup Institute also purchased participants from other panels to obtain sufficient cases for specific population groups in small federal states (e.g., Burgenland).For stratification, the following characteristics were used: age, gender, formal education, employment status, federal regions, and degree of urbanization.The Austrian Nutrition Literacy Survey 2021 was conducted between October 11 and November 8, 2021.The questionnaire was previously field tested (n = 48).In this context, the comprehensibility of the questions, technical deficiencies in the programming of the questionnaire, and the duration of the survey were examined.The field test did not reveal any problems.
Deviations in the composition of the sample from the population were adjusted by weighting for age, sex, formal education, employment status, federal regions, and degree of urbanization.Weighting was performed using the Random Iterative Method (RIM) with weights ranging from 0.173 to 5.608.Table 1 shows the distribution of the target population and the distribution of the unweighted sample and the weighted data according to the variables mentioned.The weighted data are broadly representative of the web-savvy adult population in Austria.

Participants
The total sample consists of 2,993 adults aged 18 years and over.51% are women.The mean and median age are 48.3 (± 16.5) and 48.0 years, respectively.In terms of educational attainment, most participants have completed intermediate vocational education or vocational training; in terms of employment status, most participants are employed; and in terms of level of urbanisation, most participants live in a city (see Table 1).

Analysis
To test the factorial validity/dimensionality of the new NHLS and the slightly adapted SPFL, we conducted exploratory factor analyses (EFA) to examine the factor structure of the instruments and confirmatory factor analyses (CFA) to test whether the data fit the theoretically hypothesised factor model.
Principal axis factoring (PAF) was used as the EFA extraction method.Oblimin with Kaiser normalisation was chosen as the rotation method.Factor loadings should be greater than or equal to 0.5 [23].
The internal consistency of the instruments was assessed using Cronbach's Alpha, Ordinal Alpha, and McDonald's Omega.For all parameters, a value of 0.70 or higher is considered acceptable [21,27].Following the recommendation by Fornell & Larcker [20], the average variance extracted (AVE) was calculated.The AVE should be 0.5 or greater so that the amount of variation captured by the measurement instrument is not smaller than the variance due to measurement error.
The mean, standard deviation, median, percentiles, skewness and kurtosis are calculated to describe the distribution of the NHLS and the SPFL-SF score.
Analyses were performed on the weighted data using SPSS or the R package lavaan1 [28].

Exploratory factor analysis
Examining the item set of the adapted and further developed NHLS, four dimensions reflecting accessing, a People who reported being diverse were not included in the analyses due to their small numbers b Retired, unable to work for health reasons, student, purely fulfilling domestic tasks, in compulsory military or civilian service understanding, appraising, and applying nutrition-related information were found in the EFA.To balance the number of items per dimensions represented, the instrument was shortened to 12 items (three items per dimension).
The factor structure of the slightly adapted SPFL, consisting of 29 + 1 items, revealed ten dimensions representing different aspects of FL.This is two more dimensions than those reported by Poelman et al. [18], with the two additional dimensions further differentiating two original dimensions: The dimension "food preparation skills" is subdivided into "healthy cooking" and "assessing food quality", the dimension "resilience and resistance" is subdivided into "resisting temptations" and "healthy eating in exceptional situations".Each of the dimension consists of a different number of items and therefore has a different impact on the overall SPFL score.To obtain a shorter, more concise, and balanced instrument, a short version (SPFL-SF) with only two items per dimension was developed based on content and statistical considerations in consultation with nutrition experts.

Confirmative factor analysis
A test of the factor structure of the NHLS based on the original 16 items (corresponding to the four sub-dimensions and considering a hierarchical factor structure) did not result in a satisfactory data model fit.To obtain a shorter and balanced version, the item set was reduced to 12 items (three items per sub-dimension) based on content and statistical considerations in consultation with nutrition experts.The reduced item set (see Fig. 1) provided an excellent fit to the model (Table 2).All factor loadings are above a value of 0.5 and no correlations of residuals > 0.2 were found.
Testing of the 20-item SPFL-SF shows an excellent fit of the data to the hypothesized 10-factor model (Table 2).All factor loadings are above a value of 0.5 and no correlations of residuals > 0.2 were found.The SPFL-SF is highly correlated with the long form of the SPFL (r = 0.942, p < 0.001).(Fig. 2) Reliability A Cronbach's alpha of 0.91 indicates excellent internal consistency for the NHL scale.The lowest Cronbach's alpha value for the subdimensions of the NHLS is still acceptable at 0.71.The Cronbach's alpha of the SPFL-SF is sufficient with 0.77.However, one sub-dimension is below the threshold (resisting temptation; α = 0.61), but all sub-dimensions consist of only two items.2).

Distribution of the NHLS and SPFL-SF items
Table 3 provides information on the distribution of the 12 NHLS items (mean, standard deviation (SD), and proportion of respondents answering the extreme categories "very difficult" and "very easy".Five NHLS items were rated as "very easy" by about one-fifth to one-quarter of respondents (NHL1, NHL2, NHL3, NHL4, and NHL10), indicating that these items are easy to endorse.For all other items the value is below 16%.Three of the five items represent the sub-dimension "accessing".
The items vary in difficulty, with the percentage of "very difficult" ratings ranging from 2 to 11%, and "very easy" ratings ranging from 8 to 24%.
There were no missing values, indicating that the items were understandable and suitable.
Table 4 shows information on the distribution of the 20 SPFL-SF items (mean, standard deviation (SD), and proportion of respondents answering the extreme categories "no, never" and "yes, always".Eight of the SPFL-SF items were rated either as "no, never" (SPFL9 and SPFL14) or "yes, always" (SPFL1, SPFL2, SPFL4, SPFL13, SPFL19, and SPFL20).For ten items the value is ≤ 15%.Six of the eight items represent the sub-dimensions "healthy groceries", "healthy cooking", and "eating in company".
The responses to the SPFL-SF items vary in their level of agreement, with "no, never" responses ranging from 1 to 29%, and "yes, always" responses ranging from 5 to 52%.
Again, the lack of missing values indicates that the SPFL-SF items were understandable and suitable.

Distribution of the NHLS and SPFL-SF score
The NHLS and SPFL-SF scores and their sub-scores are calculated as additive sum values, scaled from 0 to 100.To calculate SPFL-SF scores and sub-scores, items SPFL9, SPFL10 and SPFL14 must be reverse coded (5 = 1, 4 = 2, 3 = 3, 2 = 4, 1 = 5).Scores are calculated only if all items are answered validly.For all scores, a higher value indicates better results.
The mean and median of the NHLS are around 60 points, with a SD of 18.5 points (see Table 5).The distribution of the NHLS score is slightly left-skewed and mesokurtic.The mean scores of the four sub-dimensions, accessing, understanding, appraising, and applying, range from about 51 and 68 points.(Fig. 3) The mean and median SPFL-SF score are approximately 62 points with a SD of 10.8 points.The distribution is slightly left-skewed and leptokurtic (see Table 5).The mean scores of the ten sub-dimensions range from about 44 and 79 points.

Discussion
The aim of the study was to validate two short instruments, one measuring NHL and one measuring FL.Our results indicate that the reduced item set of the adapted and further developed NHLS shows an excellent datamodel fit as well as an excellent internal consistency.The same is true for the SPFL-SF, which also showed an excellent data-model fit and sufficient internal consistency for all but one sub-dimension.The results confirm the findings of Poelman et al. [2018], with two additional dimensions that further differentiate two of the original dimensions of FL.As the ten sub-dimensions cannot be hierarchically assigned to a factor, the calculation of the SPFL-SF score follows a formative logic [29].Both instruments are balanced as the dimensions consist of the same number of items.In addition, the measures are understandable and appropriate, as evidenced by the absence of missing values in the sample.In both cases, the items vary in their difficulty or level of agreement.
As shown in a systematic review [16], instruments for measuring nutrition literacy predominantly focus on a functional understanding, such as reading skills and comprehension of nutritional information.The NHLS, however, is based on a more comprehensive public health-oriented understanding of NHL [8].
Existing measures of FL [15] often refer to the definition of FL by Vidgen and Gallegos [13], but in most cases are quite lengthy.In contrast, the SPFL-SF provides a more concise way to measure FL in its facets.

Limitations
The sample used to validate the two instruments (NHLS and SPFL-SF) is based on an online survey.Therefore, not all population groups were reached equally well (e.g., elderly people).Furthermore, the survey was conducted in German only.The sample is therefore representative of the web-savvy, German-speaking adult population in Austria.It should also be noted that these are self-assessment tools.

Conclusions
Both instruments (NHLS and SPFL-SF) have excellent factorial validity and sufficient internal consistency.The short instruments have been conceptually developed and validated with nutrition experts.Because of their brief nature, they are particularly suitable for measuring different aspects of nutrition literacy in nutrition studies or evaluation studies.Other aspects of validity need to be investigated in further studies.

Use of the instruments
The NHLS and SPFL-SF have been developed by Gesundheit Österreich GmbH (GÖG).They can be used free of charge by third parties for research purposes but require a contractual agreement between the user and GÖG.Please contact the corresponding author.

Fig. 1
Fig. 1 Confirmatory factor analysis of the NHLS as a hierarchical model with four sub-dimensions, factor loadings (weighted data, n = 2993)

Table 3
Descriptive results for the NHLS items (weighted data, n = 2993)

Table 4
(18)riptive results for the SPFL-SF items (weighted data, n = 2993)Note The English version of the SPFL-SF is based on Poelman et al.(18)and has been adapted for items SPFL1, SPFL3 and SPFL4 a Item was slightly adjusted (originally: Do you purchase healthy food, even if you have limited money?)